The 3 Decade Wait for the National Social Health Insurance Scheme In Uganda

Globally, World Health Orgnisation (WHO) has  been  pushing  for universal health coverage with a goal of ensuring that all people obtain the health services they need without suffering financial hardship. It was a policy adopted to ensure continued progress towards the current health Millennium Development Goals by 2030by various state signatories.

Whereas that’s the case, many Ugandans still find themselves spending a significant amount of their income on health, which in most cases leaves many languishing in poverty notwisthstanding the government’s frequentridiculous notions of free health care provisionat public health facilities. Health is a fundamental human right whose realization requires the active participation of the various stakeholders.

At the beginning of the 21st century, the government of Uganda began implementing a series of health sector reforms that were aimed at improving the poor health indicators prevailing at the time. Among the reforms was the health financing policy since funds from the mainstream government, donors and private sector were inadequate to provide good quality health care expected by the citizens. Health insurance was proposed as alternative source to augment financing of health care.

Ministry of Health (MoH) initiated a plan to develop a national social health scheme. The purpose of the scheme was intended to diversify and strengthen health care financing and make a contribution to bridging the financing gap in the sector; to stimulate providers to avail good quality, accessible  and affordable healthcare. The development of the National Social Health Insurance Scheme (NSHIS) was hinged on the World Health Organisation (WHO) resolution, Uganda’s Constitution of 1995, the National Health Policy (1999-2009), the Health Sector Strategic Plan I, II and III and the National Development Plan (2010/11-2014/15).

The 1995 Constitution emphasised that the state should take all practical measures to ensure the provision of basic medical services to the population. In 1996, Uganda’s MoH commissioned the first feasibility study on health insurance, and some limited Community Health Insurance (CHI) pilot schemes were attempted. The feasibility study was exploratory and looked at the potential for establishing social health insurance in Uganda.

The goal of the National Health Policy (NHP) was to ensure attainment of a good standard of health by all Ugandans and to promote a healthy and productive life in an equitable manner. Ministry of health was enlisted to  explore  alternative, equitable  and  sustainable  options  for  health  financing  and  health  service  organization  targeting the  poor  and  other  vulnerable  groups.

The Health Sector Strategic Plan I (2000/1-2004/5), II (2005/6-2009/10) and III (2010/11–14/15) highlighted development of alternative health financing mechanisms among which was Social health insurance (SHI). A second feasibility study undertaken in 2001 recommended that Uganda pursues a strategy of starting up SHI gradually, by initially covering only civil servants and their families located in large cities plus workers and their families employed by large companies. The study recommended that step-by-step, the scheme could be expanded to include all workers and their families in the formal sector, and hopefully the informal sector as well.

In 2006, the Government of Uganda asked the MoH to design a health insurance scheme through a cabinet minute No. 63 (CT 2006). The Minister of Health established a national task force on health insurance, with representation from all relevant stakeholders such as MoH, Ministry of Finance, Ministry of labor and gender, Ministry of public service, trade Unions and Federation of Uganda employers to spearhead drafting of the Bill and design issues. The purpose of the Bill was to diversify and strengthen health care financing, stimulate providers to provide good quality services at affordable prices and increase welfare gain in health care through financial risk protection. It was  hoped  that  the  introduction  of  a  national  health  insurance  scheme  would  lead  the  government  to embark  on  improved  health  infrastructure,  human  and  financial  resources  and  availability  of basic  goods  and  services  as  a  holistic  revamping  of  the  provision  of  health  care  in  Uganda. However the scheme faced stiff criticism from major stakeholders, who described it as another burden to employees, expressing fears that such a policy might increase the already high cost of doing business in the country.

Later on in 2011, government directed the Minister of Health to issue additional principles of the bill to the First Parliamentary Council taking into consideration stakeholder concerns through cabinet minute 84 (CT 2011). Also the National development plan provided for the establishment of health-financing mechanisms (NHI and other community health-financing mechanisms) based on prepayment and financial risk pooling with the goal of achieving universal coverage and social health protection

In 2012, the cabinet approved National  Health  Insurance  Bill  to be tabled in parliament. But surprisingly it wasn’t passed into law. The bill was composed of three sub-schemes, including social health insurance, community-based health insurance (CBHI) largely comprising of the informal sector, and private-commercial health insurance, which would be implemented concurrently.

With the recent improvements in 2019, cabinet approved the National Health Insurance Scheme (NHIS) that required all Ugandans above 18 years to contribute to the scheme before accessing health services across the country. The bill  also intended to facilitate the provision of accessible, affordable acceptable and quality healthcare services to citizens irrespective of their age, economic, health and social status. 

Every contributor upon payment of the prescribed contribution, would be issued with a card for purposes of identification and verification. Employees in the formal sector would be subjected to 4% deductions from their salaries while their employers would contribute 1% to while individuals in the informal sector would pay a proposed Shs100,000 annually and pensioners contribute 1% of their monthly pension payment. For every contributor, a spouse and children below 18 years would access the defined benefits packages irrespective of the amount of contribution and should both wife and husband be working in the formal sector, both would have to pay for the health insurance scheme.

However, underprivileged people such as the poor who hardly earned $1.5 (about Shs5,462) a day, people with disability, the elderly, orphans, street children and people above 18 years with no formal or informal employment would not pay any fee, but would get insurance cards from the government to access health services. Individuals without an insurance card would not access health services but immunization since free medication in all hospitals would be phased out, once the Bill was enacted. Individuals with emergencies, including those involved in accidents, would be able to access free services even without the health insurance card.

Realization of the National Health Insurance Scheme has been complicated by low income levels of most Ugandans who incapable of paying mandatory costs.

The National Social health insurance scheme is commendable and  if  streamlined  to  the  current  needs  in  the  sector,  will  go  far in respect to the realisation of the right to health for all Ugandans as stipulated in international, regional and national legal/policy frameworks. However, there are some challenges and constraints that need to be adressed if  the  bill  is  going to address  the practical  realities  of our traditional  family set  up and the  underlying  health  problems.

In Uganda,  the  working  legal  definition  of  a  child  is anyone  below  the  age  of 18. The  people that  stand to  benefit  largely from  this scheme  are  mainly  rural  based,  poor and  unemployed who  normally  live in  extended  family  setups  with  many  children  and  young  adults  from  dead relatives  or  others  unable  to  take  care  of  their  own.  This  is  a  reality  in  Uganda  and  families  don’t normally  go  through  the  intricate  legal  process  of  adoption.  Therefore,  this  clause  as  is  proposed automatically   excludes   many   children   who  are  under  mere   guardianship   or  foster  care placement.  There  is  need  to  harmonize with  the  extended  family  set  up  without  necessarily  opening  up  more  case  load  for  the  judiciary  in  adoption  applications  which are  in  themselves  not  practical  under  temporal  foster  care  and  guardianship,  which  is  a  norm  in traditional  society Uganda.

Enrolment is legally mandatory but non-compliance is an obstacle that faces this scheme if implemented, as it is a social policy that is difficult to enforce, given the large informal sector for which there is no database and the need for formal sector workers to voluntarily pay a registration fee to be enrolled. This is solely due to the fact that employers are not comfortable paying NSSF, PAYE and other deductions.

In addition, emerging evidence reveals a variety of implementation problems such as the perceived poor quality of health care, delays that may arise out of NSHIS card production and distribution, lack of trust in scheme management, long waiting times for insured clients and high enrolment dropout rates.

The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the four phases of development: from 1995 to 1999; 2000 to 2005; 2006 to 2011 and 2012- 2019. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Ministry of Health following a directive from the President, withdrew the National Health Insurance Bill in 2020. The country has been waiting for this scheme for more than 10 years. The ministry has spent 20 years designing it. Of the three East African countries; Kenya, Tanzania and Rwanda, only Uganda is without National Social Health Insurance Scheme. It should be noted, that the law alone, no matter how sound it is, cannot effect meaningful transformation without the political will to address the challenges that affect the realisation of the right to universal health care.

Peter Kabuye is a student of Dental Surgery at Uganda Christian University.

@peterkabuye on Twitter.

Peter Kabuye
I am a third-year student at Uganda Christian University currently majoring in dental surgery. I am highly interested in matters concerning leadership, management, finance, and dental surgery.